Provider Demographics
NPI:1457922692
Name:CHIDIADI, OKECHUKWU C (PMHNP)
Entity type:Individual
Prefix:
First Name:OKECHUKWU
Middle Name:C
Last Name:CHIDIADI
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MARK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-1435
Mailing Address - Country:US
Mailing Address - Phone:860-869-5030
Mailing Address - Fax:
Practice Address - Street 1:92 MARK DR
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-1435
Practice Address - Country:US
Practice Address - Phone:860-869-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009779363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health